Endoscopic Band Ligation Compared With Endoscopic Submucosal Dissection For Removal of Muscularis Propria Originated Small Neoplasms

Results: Forty-nine patients (96.1%) in EBL successfully completed endoscopic procedures. Of the 49 patients adopted EBL, 1 patient developed post-operation perforation and 2 patients complicated with minor bleeding. During follow-up period (2 weeks-12 months), all 49 neoplasms fell off, with none relapsed. In ESD group, 52 patients (96.3%) successfully completed endoscopic procedure and 2 patients switched to open surgery for adhesion. Fourteen patients went through initiative perforation. None relapsed during follow-up (3 months-12 months). As for post-procedure complications, the two groups showed similar rate (6.1%, 3/49 vs. 0%, 0/52, P = 0.070). EBL group showed significantly shorter operating time (16.2±3.7 min vs. 73.2±36.4 min, P = 0.001), post-procedure fasting time (1.3±0.7 d vs. 3.8±1.4d, P = 0.001), hospital stay (2.8±0.9 d vs. 5.7±1.4 d, P = 0.001), and lower cost (9000 ¥±3000 ¥ vs. 19000 ¥±3000 ¥, P = 0.001).


Introduction
With rapid development of endoscopic ultrasonography (EUS), detecting rate of upper digestive tract muscularis propria originated small neoplasms is increasing. Histologically, muscularis propria originated neoplasms are divided into gastrointestinal stromal tumors (GIST), liomyoma, schwannoma and calcified fibrous tumor.
Though for most small neoplasms, regular endoscopic followup shows lower risk, but patients would develop great mental burden. Taking into carcinogenesis potential of GIST and liomyoma, endoscopic procedures with safety, efficacy and convenience were now back to field. As for endoscopic procedures of such lesions, endoscopic band ligation (EBL) and endoscopic submucosal dissection (ESD) have been widely used now. ESD is now widely used in submucosal lesion dissection, but with limitation of relative long learning period, complicated procedures. Compared with ESD, EBL shows better convenience, but lacks pathological studies for random discharge of neoplasms. So herein, we conducted a retrospective case-control study to investigate the treatment value of ESD and EBL in muscularis propria originated small neoplasms.

Pre-Procedure Evaluation
Patients underwent gastric endoscopy, endoscopic ultrasonography, abdominal CT scan for pre-procedure evaluation of size, location and type of neoplasm. And routine chest X-ray, electrocardiogram, pulmonary function, blood routine, biochemical analysis, coagulation function were completed before procedure.

Endoscopic Procedures
For EBL group, routine procedures were as follows: place

Post-Procedure Treatment and Follow-Up
For EBL, fast for one day after procedure, and routine antiacid therapy, mucous protection agent for two weeks. Repeat endoscopic ultrasonography or endoscopy for 2 weeks or 3 months.
For ESD group, fast, gastrointestinal decompression, anti-acid and parenteral nutrition for two to three days as for routine patients. The time might be extended to one week for endoscopic full-thickness resection (EFR) patients, and anti-biotics might be used in addition.
Routine anti-acid therapy, mucous protection agent were used till two months and followed up with endoscopic ultrasonography or endoscopy for 3 months to 1 year.

Statistical Analysis
Data collected included demographic, clinical data as well as operating time, post-operate fast time, hospital stay and cost.

Peri-Procedure Comparison
One patient in EBL group complicated with acute perforation, and successfully treated with purse string suture; two had minor bleeding after procedure and treated conservatively. 13 patients in ESD group had fever after procedure, but none complicated with gastric intestinal bleeding or severe infection or even death.
Post-procedure complication rate showed no significant difference between two groups (P > 0.05 for all). But as for procedure time, post-procedure fast time, hospital stay and cost, EBL group were all lower (P < 0.05 for all,) ( Table 2).

Follow-Up Conditions
Follow up duration in EBL group varied from 2 weeks to one year, and none of 49 patients showed recurrence. As for ESD group, post-procedure endoscopy in three to 12 months after procedure was all negative as well.  leiomyoma [4]. EBL showed better accessibility, convenience, less trauma, shorter hospital stay and lower cost [4]. EBL is relatively safe that after ligation of whole layer of stomach, tumor would fall off after ischemia and necrosis, and left ulcer will be healed in a short period. However, in our study, one patient in EBL group had acute perforation after procedure, might be owing to early fall off of band. In order to avoid such complication, titanium clip can be used. As diameter of transparent cap is limited, for tumor greater than 12mm, complete suction was hard, so longer suction time is needed [5]. One limitation for EBL is that usually tumor fall of time is long and random, so pathological analysis is not applicable. In our study, ESD group showed 44.4% GISTs, 42.6% liomyoma, which all turned to be low or extreme low degree.
So, clinically, close follow up is needed to ensure fall off of tumor as well as recurrence and in our study, after 2 weeks to 12 months post-procedure follow up, all tumors were off, and none had recurrence. ESD is now widely used endoscopic technology for dissection of muscularis propria tumors with application of endoscopy, knife, injecting needle, transparent cap, titanium clip, coagulation clamp. Advantage of ESD is ability to gain pathological evidence. As endoscopic skills and equipment develop rapidly, for tumors invaded into serosa, EFR is also safe and effective [6]. Once perforation happened, titanium clip can be used to close small wound (<3cm), while larger wound would be closed by purse string suture [7]. In our study, 14 patients ender went EFR, adopted purse string suture and none switched to surgery or had post-procedure bleeding. For muscularis propria tumor less than 3cm, compared with surgery, ESD has less trauma, lower hospital stay and quick recovery [8].

Conclusion
In conclusion, as for small neoplasm derived from muscularis propria, compared with EBL, ESD group showed lower procedure time, post-procedure fast time, hospital stay with no increase in peri-procedure complications.